Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

/pdf/guidelines-for-the-early-management-of-patients-with-acute-19udbft6e7.pdf

Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Summary Background Previous studies have suggested that desmoteplase, a novel plasminogen activator, has clinical benefit when given 3–9 h after the onset of the symptoms of stroke in patients with presumptive tissue at risk that is identified by magnetic resonance perfusion imaging (PI) and diffusion-weighted imaging (DWI). Methods In this randomised, placebo-controlled, double-blind, dose-ranging study, patients with acute ischaemic stroke and tissue at risk seen on either MRI or CT imaging were randomly assigned (1:1:1) to 90 μg/kg desmoteplase, 125 μg/kg desmoteplase, or placebo within 3–9 h after the onset of symptoms of stroke. The primary endpoint was clinical response rates at day 90, defined as a composite of improvement in National Institutes of Health stroke scale (NIHSS) score of 8 points or more or an NIHSS score of 1 point or less, a modified Rankin scale score of 0–2 points, and a Barthel index of 75–100. Secondary endpoints included change in lesion volume between baseline and day 30, rates of symptomatic intracranial haemorrhage, and mortality rates. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, NCT00111852. Findings Between June, 2005, and March, 2007, 193 patients were randomised, and 186 patients received treatment: 57 received 90 μg/kg desmoteplase; 66 received 125 μg/kg desmoteplase; and 63 received placebo. 158 patients completed the study. The median baseline NIHSS score was 9 (IQR 6–14) points, and 30% (53 of 179) of the patients had a visible occlusion of a vessel at presentation. The core lesion and the mismatch volumes were small (median volumes were 10·6 cm 3 and 52·5 cm 3 , respectively). The clinical response rates at day 90 were 47% (27 of 57) for 90 μg/kg desmoteplase, 36% (24 of 66) for 125 μg/kg desmoteplase, and 46% (29 of 63) for placebo. The median changes in lesion volume were: 90 μg/kg desmoteplase 14·0% (0·5 cm 3 ); 125 μg/kg desmoteplase 10·8% (0·3 cm 3 ); placebo −10·0% (−0·9 cm 3 ). The rates of symptomatic intracranial haemorrhage were 3·5% (2 of 57) for 90 μg/kg desmoteplase, 4·5% (3 of 66) for 125 μg/kg desmoteplase, and 0% for placebo. The overall mortality rate was 11% (5% [3 of 57] for 90 μg/kg desmoteplase; 21% [14 of 66] for 125 μg/kg desmoteplase; and 6% [4 of 63] for placebo). Interpretation The DIAS-2 study did not show a benefit of desmoteplase given 3–9 h after the onset of stroke. The high response rate in the placebo group could be explained by the mild strokes recorded (low baseline NIHSS scores, small core lesions, and small mismatch volumes that were associated with no vessel occlusions), which possibly reduced the potential to detect any effect of desmoteplase. Funding PAION Deutschland GmbH; Forest Laboratories.

/pdf/intravenous-desmoteplase-in-patients-with-acute-ischaemic-4uf7crvjbs.pdf

Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study.

Objective: To update a 15-year-old study of 800 postlinguistically deaf adult patients showing how duration of severe to profound hearing loss, age at cochlear implantation (CI), age at onset of severe to profound hearing loss, etiology and CI experience affected CI outcome. Study Design: Retrospective multicenter study. Methods: Data from 2251 adult patients implanted since 2003 in 15 international centers were collected and speech scores in quiet were converted to percentile ranks to remove differences between centers. Results: The negative effect of long duration of severe to profound hearing loss was less important in the new data than in 1996; the effects of age at CI and age at onset of severe to profound hearing loss were delayed until older ages; etiology had a smaller effect, and the effect of CI experience was greater with a steeper learning curve. Patients with longer durations of severe to profound hearing loss were less likely to improve with CI experience than patients with shorter duration of severe to profound hearing loss. Conclusions: The factors that were relevant in 1996 were still relevant in 2011, although their relative importance had changed. Relaxed patient selection criteria, improved clinical management of hearing loss, modifications of surgical practice, and improved devices may explain the differences.

/pdf/factors-affecting-auditory-performance-of-postlinguistically-39eiz61pbt.pdf

Factors Affecting Auditory Performance of Postlinguistically Deaf Adults Using Cochlear Implants: An Update with 2251 Patients

Background—Age-related dementia, most commonly caused by Alzheimer disease or cerebrovascular factors (vascular dementia), is a major public health threat. Chronic arterial hypertension is a well-e...

Impact of Hypertension on Cognitive Function: A Scientific Statement From the American Heart Association

Background and Purpose— Different definitions have been proposed to define the ischemic penumbra from perfusion-CT (PCT) data, based on parameters and thresholds tested only in small pilot studies. The purpose of this study was to perform a systematic evaluation of all PCT parameters (cerebral blood flow, volume [CBV], mean transit time [MTT], time-to-peak) in a large series of acute stroke patients, to determine which (combination of) parameters most accurately predicts infarct and penumbra. Methods— One hundred and thirty patients with symptoms suggesting hemispheric stroke ≤12 hours from onset were enrolled in a prospective multicenter trial. They all underwent admission PCT and follow-up diffusion-weighted imaging/fluid-attenuated inversion recovery (DWI/FLAIR); 25 patients also underwent admission DWI/FLAIR. PCT maps were assessed for absolute and relative reduced CBV, reduced cerebral blood flow, increased MTT, and increased time-to-peak. Receiver-operating characteristic curve analysis was performe...

Perfusion-CT Assessment of Infarct Core and Penumbra Receiver Operating Characteristic Curve Analysis in 130 Patients Suspected of Acute Hemispheric Stroke

An apparatus for measuring parameters (276) preparatory to a stent replacement of an aneurytic blood vessel in a patient (26) includes a computed tomography (CT) scanner (10) that acquires image data (28) corresponding to multiple two-dimensional image slices. A reconstruction processor (32) reconstructs a three-dimensional image representation (34) from the image data (28) .A tracking processor (40) produces a tracked vessel (92) including at least a centerline (144) and selected vessel boundaries (204). A user interface (44) displays a rendering (242) of the image representation to an associated user (42), measures selected vascular parameters corresponding to the stent parameters (276), and graphically superimposes the measured parameters on the rendering of the image representation (270, 272).

Method and apparatus for semi-automatic aneurysm measurement and stent planning using volume image data

BACKGROUND AND PURPOSE: The Patlak model has been applied to first-pass perfusion CT (PCT) data to extract information on blood-brain barrier permeability (BBBP) to predict hemorrhagic transformation in patients with acute stroke. However, the Patlak model was originally described for the delayed steady-state phase of contrast circulation. The goal of this study was to assess whether the first pass or the delayed phase of a contrast bolus injection better respects the assumptions of the Patlak model for the assessment of BBBP in patients with acute stroke by using PCT. MATERIALS AND METHODS: We retrospectively identified 125 consecutive patients (29 with acute hemispheric stroke and 96 without) who underwent a PCT study by using a prolonged acquisition time up to 3 minutes. The Patlak model was applied to calculate BBBP in ischemic and nonischemic brain tissue. Linear regression of the Patlak plot was performed separately for the first pass and for the delayed phase of the contrast bolus injection. Patlak linear regression models for the first pass and the delayed phase were compared in terms of their respective square root mean squared errors (√MSE) and correlation coefficients (R) by using generalized estimating equations with robust variance estimation. RESULTS: BBBP values calculated from the first pass were significantly higher than those from the delayed phase, both in nonischemic brain tissue (2.81 mL × 100 g−1 × min−1 for the first pass versus 1.05 mL × 100 g−1 × min−1 for the delayed phase, P CONCLUSION: Only the delayed phase of PCT acquisition respects the assumptions of linearity of the Patlak model in patients with and without stroke.

http://www.ajnr.org/content/ajnr/29/9/1671.full.pdf

Dynamic perfusion CT assessment of the blood-brain barrier permeability: first pass versus delayed acquisition.

A CT scanner (10) for obtaining a medical diagnostic image of a subject includes a stationary gantry (12), and a rotating gantry (14) rotatably supported on the stationary gantry (12) for rotation about the subject. In a perfusion study (130 ) time-density curves of voxels of an imaging region are computed. In a low signal identification step (132), all voxels with low signal are identified. In a clustering step (134), low signal voxels are clustered together. In a representative determination step (136) representative time-density curves are computed. In a functional measurement step (138), measurements are calculated from the combined and uncombined time-density values. In an assigning step (140), each low signal voxel is assigned the values determined for its group. In a combining step (142) the results of the low and normal signal voxels are combined to produce a single functional perfusion image.

Low signal correction for perfusion measurements

A CT scanner ( 10 ) for obtaining a medical diagnostic image of a subject includes a stationary gantry ( 12 ), and a rotating gantry ( 14 ). The detected radiation is reconstructed and divided into sub-portions, which sub-portions are aligned by a registration processor ( 56 ). The registered images are stored in a high resolution memory ( 58 ) and a maximum artery enhancement value is calculated from the high resolution images. A resolution reducer ( 82 ) reduces the resolution of the high resolution images. Time-density curves are found for the voxels of the images, which time-density curves are truncated to eliminate unwanted data, and analyzed to determine characteristic values. A perfusion calculator ( 106 ) calculates perfusion by using the maximum artery enhancement value and the characteristic values. A diagnostician can view any one of a low resolution image, a high resolution image, and a perfusion image on a video monitor ( 112 ).

Scott Pohlman

Papers

Perfusion-CT Assessment of Infarct Core and Penumbra Receiver Operating Characteristic Curve Analysis in 130 Patients Suspected of Acute Hemispheric Stroke

Method and apparatus for semi-automatic aneurysm measurement and stent planning using volume image data

Dynamic perfusion CT assessment of the blood-brain barrier permeability: first pass versus delayed acquisition.

Low signal correction for perfusion measurements

Measurements with CT perfusion